NCC215279_FRO Submitted_20210924

DURHAM
COUNTY
�NC
0�81
Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
WITH LANDOWNER CONSENT FORM
No person may initiate any land -disturbing activity covered by the Durham City -County Unified Development Ordinance before a
Land Disturbing Permit is issued by the Sedimentation and Erosion Control Office. Issuance of a Land Disturbing Permit does not
relieve the permittee of the obligation to obtain any other licenses, permits and approvals as may be required by Federal, State,
County or Municipal governments. This office must be notified in writing of any change to the information on this form.
PLEASE TYPE OR PRINT
1. Project name: Patriot Business Park Buildings 5
2. Road location of land -disturbing activity: National Way
Tax Map - Block - Parcel: 226305
PIN: 0748-64-26-2842
3. Square footage of land to be disturbed or uncovered: 631,620 SF - 14.5 Acres
4. List below the landowner of record. Each landowner must complete Item 8.
(If there are multiple owners, please list on a separate page):
SCP Patriot Lot5 LLC
Name
8900 Keystone Crossing, Suite 100
Address
city
Indianapolis, IN 46240
State Zip
317-819-1871 [e-mail]
Telephone Fax Email
5. List the person or entity financially responsible for this land -disturbing activity: The financially responsible party shall
be (1) the developer or other person who has or holds themselves as having financial or operational control over the land -
disturbing activity and/or (2) the land owner or person in possession or control of the land when they have directly or indirectly
allowed the land -disturbing activity or have benefited from it and (3) the named party on the Land Disturbing Permit.
Same as above
Name
Street Address
City State Zip
Telephone
Fax
Email
The Sedimentation and Pollution Control Act (Act) and the Durham City -County Unified Development Ordinance (Ordinance)
includes, but is not limited to, the following legal obligations of the financially responsible party:
■ Maintain a set of approved sedimentation and erosion control plans, if required, on site.
A Display permit on site.
■ Understand and implement any required plan, including the construction sequence and details.
• Inspect, maintain and repair sedimentation and erosion control measures, especially after rainfall events.
■ Refer to Section 12.10.413 of the Durham City/County UDO for groundcover time line requirements.
+ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
120 E. Parrish Street, Law Bldg., I" Floor, Durham, N.C. 27701 a [phone] * Fax [phone]
www.deone.gov/index.aspx?page=180

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
DCI - Development and Construction Insight. LLC
Name
2054 Kildaire Farm Road #167
Street Address
—Cary, NC 27518
City State Zip
919-868-3099 [e-mail]
Telephone Fax Email
7. The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath. I
understand that the person or entity listed on Line 5 above will be: (1) the owner of the Land Disturbing Permit when issued;
(2) responsible for ensuring compliance with the Act and Ordinance; and, (3) will be the only person or entity with standing to
appeal any action taken or decision made by the Sedimentation and Erosion Control Office.
1 Richard Horn
Date Type or Print Name
317-819-1881 Member - Manager
Telephone Fax Title or At,th�tw'�
[e-mail]
Email Signature
Business Applicant (Provide comorate resolution on sianatory authori
I, ,^ �I ' a Notary Public of the Coo�untty/_of ��'Y1 t 1'f DI-)
State of 1r 16(4--)^ , hereby certify that L.41�IT'S-- may- air,
personally came before me this day and acknowledged that he is m O A n6i
of SDI-lyPo-fn`Df L01- s6 L-1-C and acknowledged, on behalf of � ���p_ � s�F'GLt' 6 YI Yywal.e'_
/nSi,Y� f, 44c-
the due execution of the foregoing instrument.
Witness my hand and official seal, this
day of
My commission expires �� ) 1", _'20 24
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Individual Applicant
I,
State
a Notary Public of the County of
hereby certify that
20 Zj
DINA L RANDALL
Notary Public - Seal
Hamilton County - State of Indiana
. +. ■ �Se«am1 rsi�rw Me►rn beR �R9;:�� * *+
My Commission Expires Jun 16, 2028
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal, this
My commission expires
day of
Notary Public
20
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE
120

Provide a Notarized Item 8 for each landowner listed in Item 4.
8. Land Owner Consent. As a landowner, I provide my consent for land -disturbing activities to occur on the property listed in
Item 2 by the person or entity listed in Item 5.
/3 'ZOZ-/ Richard Horn
Date 317-819-1881 Type or Print Name
Member - Manager
Telephone Fax Title Dr ihorii
rhorn@strate_qiccapitalpartners.com �L
Email Signature
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Business Landowner (Provide corOnrate resolution on signatory authorit
I, D i r. L- XJ,i,)Aj. it , a Notary Public of the County of _ ±64=,'yI / `JZ ►
Jf
State of I � -lifgek _ , hereby certify that_ jejCj- q l z,( L'J : HV r'n -
personally came before me this day and acknowledged that he is Me"Aci r— /VlA.ng
of �1("r" +t qv fo f Lod" 5 Li-C, and acknowledged, on behalf of /J — ��'�+%��_a� GCvI-shuck p; ;
IriS�, LLB.
, the due execution of the foregoing instrument.
Witness my hand and official seal, this / 3 day of , 20 Z/
�" Nd+ar�Public
My commission expires °1 �' f 20 22 DINA L RANDALL
Notary Public - Seal
Hamilton County . State of Indiana
My Commission Expires Jun 16, 2028
Individual Landowner
I,
State of
a Notary Public of the County of
hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal, this
My commission expires
day of
Notary Public
20
20
SE-03 Rev. 10/13